Circulation July 19, 2022 Issue

This week, please join Associate Editors Mercedes
Carnethon and Karol Watson, as well as Guest Editor Fatima
Rodriguez as they present the 2nd annual Disparities Issue. Then
join Rishi Wadhera and Ashley Kyalwazi as they discuss their
article "Disparities in Cardiovascular Mortality Between Black
and White Adults in the United States, 1999 to 2019."


Dr. Mercedes Carnethon:


Well, good day listeners. I'm Mercedes Carnethon, and I'm joined
by my fellow editors, Karol Watson, and Fatima Rodriguez,
Associate Editor and Guest Editor for Circulation. And we'd like
to welcome you to Circulation on the Run, for our second annual
disparities issue. We have a lot of articles to discuss today,
many of which we'll summarize, but we encourage you to access the
issue and read the articles. First off, Fatima, I believe you
have a paper to discuss.


Dr. Fatima Rodriguez:


Sure thing, Merci. My first paper is a thought provoking article
by Nilay Shah, and co-authors from Northwestern University, that
examine factors associated with the racial gap in premature
cardiovascular disease.


Dr. Fatima Rodriguez:


This study used data from a well-known cardiac cohort, that aims
to identify factors that begin in young adulthood and predict the
development of future coronary artery risk. The objective of this
study was to examine the relative contributions of clinical
versus social factors, in explaining the persistent black/white
gap in premature cardiovascular disease. After following around
5,000 black and white study participants for a median of 34
years, black men and women had a higher risk of premature
cardiovascular disease. After controlling for multi-level
individual and neighborhood level factors measured in young
adulthood, the racial differences in premature cardiovascular
disease were attenuated.


Dr. Fatima Rodriguez:


The authors found that the greater contributors to this racial
disparity were not only clinical factors, but also neighborhood
and socioeconomic factors. The relative explanatory power of each
of these factors varied by men and women. This is really
noteworthy, since we spent so much of our time in clinical
medicine, focusing on identifying and managing traditional risk
factors. But in reality, these structural factors and inequities
are critically important to address, and contribute to
differences in clinical risk factors downstream.


Dr. Mercedes Carnethon:


Thank you so much, Fatima. That was a really excellent summary.
And now, I'm turning to you, Karol. I'd love to hear what you're
going to be talking about today.


Dr. Karol Watson:


I'd like to discuss the paper, Association of Neighborhood Level
Material Deprivation with Atrial Fibrillation Care in a
Single-Payer Healthcare System Population Based Cohort Study.
This is by Dr. Abdel-Qadir and colleagues.


Dr. Karol Watson:


So in this study, the author sought to determine whether there
was an association between neighborhood material deprivation, by
that we mean, inability to attain the basic needs of life and
clinical outcomes, in individuals with atrial fibrillation. The
kicker here is, they did this in an area with universal
healthcare. So they wanted to see, if you took away the
differences between the ability to see a physician or get your
drugs paid for, if you would see any disparities.


Dr. Karol Watson:


So they performed a population based cohort study, individuals
over the age of 66 years of age with atrial fibrillation, in the
Canadian province of Ontario. They have universal healthcare
there, and full drug coverage for anyone over 65. The primary
exposure was neighborhood material deprivation. That's a metric
used to estimate the inability to attain basic material needs,
like healthy foods, safe housing. Neighborhoods were categorized
by quintile, from the least deprived, quintile one, to the most
deprived, quintile five. They find that, among about 350,000
individuals with atrial fibrillation, their mean age was 79, and
about half of them were women. Those in the most deprived
neighborhoods, quintile five, had a higher prevalence of
cardiovascular risk factors and non-cardiovascular work
comorbidity, relative to those who were in the least deprived
areas.


Dr. Karol Watson:


Even after adjusting for all the confounders, they found that
those in the most deprived neighborhoods had higher hazards of
death, stroke, heart failure, and bleeding, relative to those in
the least deprived neighborhoods. They also found that, despite
having universal healthcare and drug coverage, those in the most
deprived neighborhoods were less likely to visit a cardiologist,
less likely to receive rhythm control intervention, such as
ablation, and have worse outcomes.


Dr. Karol Watson:


And then, the accompanying editorial by Utibe Essien, he reminds
us that intervening only on traditional markers of access, like
health insurance and drug costs, may not be sufficient to achieve
health equity. We have to address all of the structural needs
that make people unable to get good help. Further, he points out
that, the association between atrial fibrillation and
neighborhood deprivation is very likely true with other
cardiovascular conditions, as well.


Dr. Karol Watson:


So, Merci and Fatima, this just reminds us again, that addressing
all the social determinants of health are necessary to achieve
the best health outcomes.


Dr. Mercedes Carnethon:


Thanks so much, Karol. I really appreciate that summary of that
important piece, focusing on a different domain of disparity. My
first paper is an excellent piece, led by one of my favorite
other associate editors at Circulation, Dr. Wendy Post, from
Johns Hopkins University. And I see a familiar name on here.
That's yours, Karol. You two are joined by an all-star list of
authors, to describe race and ethnic differences in all-cause in
cardiovascular mortality, in the multi-ethnic study of
atherosclerosis.


Dr. Mercedes Carnethon:


MESA is a longitudinal cohort study that launched in 2000, and
recruited just over 6,800 adults who identified as black, white,
Hispanic, and Chinese. While the study participants were
initially free from cardiovascular disease, over an average of 16
years of follow up, 364 participants died from cardiovascular
disease. There are a number of novel findings in this paper that
led our editor-in-chief to select it as his pick of the issue.


Dr. Mercedes Carnethon:


The finding that really stands out to me is, how much of an
influence the social determinants of health had on black versus
white disparities in cardiovascular mortality. In fact, after
adjusting for socioeconomic status, the disparities were nearly
eliminated. Other critically important findings are that, the oft
described Hispanic paradox of lower cardiovascular mortality in
Hispanics, as compared with white adults, was demonstrated in
this population. And finally, we have longitudinal data on Asians
living in the United States. Asian participants in MESA had
similar rates of cardiovascular disease mortality as their white
counterparts. There's so much to learn in this well designed
cohort study, and so many hypotheses about how social
determinants and structural racism influence the disparities that
we see.


Dr. Mercedes Carnethon:


So Fatima, I'd like to turn to you next. What else do you have to
share?


Dr. Fatima Rodriguez:


Thank you, Merci. My second paper is a research letter for my
home institution of Stanford University, led by my colleague, Dr.
Shoa Clarke, discussing how race and ethnicity stratification for
polygenic risk course, may mask disparities among Hispanic
individuals.


Dr. Fatima Rodriguez:


This study used data from the Million Veteran Program, to
determine how self-identified race and ethnicity impact the
performance of polygenic risk scores in predicting coronary
artery disease.


Dr. Fatima Rodriguez:


The investigators found, that the current polygenic risk scores
predict coronary artery disease similarly well in Hispanic and
non-Hispanic white individuals. However, what I found most
interesting, is that there was so much more heterogeneity among
Hispanic individuals as measured by K-Means clustering, than
among non-Hispanic white individuals. And this study really
confirms that there is much more heterogeneity within populations
than between populations. And this is particularly true as we
think of the extreme diversity of Hispanic populations. Lumping
Hispanic populations into one category, may mask important
differences in cardiovascular risk prediction outcomes, and even
the notions of the Hispanic paradox that you just discussed,
Merci.


Dr. Mercedes Carnethon:


I appreciate you bringing that up again, because there are so
many different nuances to the observations that we see in these
studies. But I'll keep moving, because we have an embarrassment
of riches in this wonderful issue. So Karol I'll turn back to
you.


Dr. Karol Watson:


Thanks, Merci. The next paper I'd like to discuss, is an On My
Mind piece by Peter Liu and colleagues, and they entitle it,
Achieving Health Equities in the Indigenous Peoples of Canada,
Learnings Adaptable for Diverse Populations. Now the author's
note that, lessons learned about addressing health disparities
from indigenous peoples in Canada, can offer a lot of new lessons
for other populations where there are similar disparities. They
begin by offering historical perspective, and they say that, most
of the health to disparities for the indigenous populations
originate from early colonization, in dismantling of the
sociocultural economic educational and health foundations, the
indigenous communities had historically.


Dr. Karol Watson:


It's true that, that is true in a number of different countries.
This is data from Canada, but we can see similar things in the
United States. With the recognition of the historical and ongoing
social health inequities, the Canadian government initiated what
they call, the Truth and Reconciliation Commission, to recommend
a path towards reconciliation, to create best practices for
engaging indigenous populations.


Dr. Karol Watson:


For instance, in Canada, any health research or implementation
program, requires the direct engagement of indigenous communities
and their elders. They have to try to develop culturally safe
environment, including what they say, quote unquote, anti-racism
and cultural safety education for all, both indigenous and
non-indigenous populations. They want to really respect community
values, customs and traditions, including the access to
traditional foods, and healing practices, and the support from
elders. So they really are making it a very important point, that
cultural sensitivity is absolutely critical to engaging these
populations. You want to jointly collect data whenever available,
to track progress and outcomes. And they offer many examples of
successful programs developed using these principles, such as the
Diabetes and My Nation program, in British Columbia, or the
mobile diabetic telehealth clinic.


Dr. Karol Watson:


They offer discussion of future initiatives as well, that can
help other communities in Canada. Such as, there's an initiative
addressing hypertension in the Chinese population in Canada.


Dr. Karol Watson:


So this thoughtful paper, really looks at disparities in unique
populations in Canada. More importantly, it offers potential
roadmaps for other populations, solutions to address longstanding
legacies of racism and colonialism.


Dr. Mercedes Carnethon:


Thank you so much, Karol, for that description from our neighbors
from the north.


Dr. Mercedes Carnethon:


My second paper is really relevant during this hot month of July,
in much of the United States and the upper hemisphere. And that's
because Sameed Khatana and colleagues from the University of
Pennsylvania, discuss how extreme heat is associated with higher
cardiovascular mortality. For those of us who welcome the heat of
summer and the opportunity to get out from behind our desks and
exposed to some vitamin D, Khatana and colleagues reviewed county
level daily data on temperature, and linked those data with
mortality rates.


Dr. Mercedes Carnethon:


But before I summarize the findings, I invite you to California
based cardiologists to join me in Chicago, where extreme heat is
really only a problem for about 30 days a year. The authors found
that between 2008 and 2017, when the heat index was above 90
degrees Fahrenheit, or 32.2 degrees Celsius, there was a
significantly higher monthly cardiovascular mortality rate. In
total, extreme heat was associated with nearly 6,000 additional
deaths from cardiovascular disease. And sadly, black adults,
older adults, and men, bore the greatest burden of mortality
rates from extreme heat. So, we can all take lessons from that.


Dr. Mercedes Carnethon:


But turning to you now, Fatima.


Dr. Fatima Rodriguez:


Thanks so much, Merci. I'm from Florida, so I can definitely
relate to the issues of extreme heat, but I'm very happy for the
perfect year round weather here in Northern California.


Dr. Fatima Rodriguez:


My third paper is led by Dr. Zubair (and Chikwe) and colleagues
from Cedar Sinai, and it describes changes in outcomes by race,
in children listed for heart transplantation in the United
States. I won't give all the details, but this research letter
really nicely summarizes how the 2016 Pediatric Heart Allocation
Policy revisions may have inadvertently widened health
disparities between white and non-white children. This article
touches on the difference between equality and equity, even in
the most well-intentioned national policies. And I invite our
listeners to read the full details in this special Circulation
edition.


Dr. Mercedes Carnethon:


Thanks Fatima. Karol.


Dr. Karol Watson:


The next paper I'd like to discuss, is a community based cluster
randomized pilot trial, of a cardiovascular mobile health
intervention, preliminary findings of the FAITH! Trial, from
LaPrincess Brewer and colleagues from the Mayo Clinic.


Dr. Karol Watson:


So it's well known that African Americans have suboptimal
cardiovascular health metrics, such as less regular physical
activity, suboptimal blood pressure levels, suboptimal diets. So
the authors of this study hypothesize, that developing a mobile
health intervention, in partnership with trusted institutions,
such as, African American churches, might be an effective means
to promote cardiovascular health in African American patients. So
using a community based participatory research approach, they
develop the FAITH! trial. FAITH stands for Fostering African
American Improvement in Total Cardiovascular Health. The
manuscript in this issue reports, feasibility and preliminary
efficacy findings from this refined community informed mobile
health intervention, using the FAITH! App, developed by the
investigators.


Dr. Karol Watson:


They performed a cluster randomized control trial. Participants
from 16 different churches in the Rochester, Minnesota and
Minneapolis St. Paul, Minnesota areas. The clusters were
randomized to receive the FAITH! App, that was the intervention
group, or were assigned to a delayed intervention program. The 10
week intervention feature culturally relative and sensitive
information modules, focused on American Heart Association's
Life's Simple 7. Primary outcomes were changes in the mean Life
Simple 7 score, from baseline to six months post intervention.
They enrolled 85 participants, mean age was 52, and about 71%
were female.


Dr. Karol Watson:


At baseline, the mean Life Simple 7 score was 6.8, and 44% of the
individuals were characterized as being in poor cardiovascular
health. The mean Life Simple 7 score of the intervention group,
after the end of the intervention, increased by 1.9 points. In
the control comparator group, it only increased by 0.7 point.
Highly statistically significant, with P value of less than
0.0001 at six months.


Dr. Karol Watson:


Now this FAITH! Trial demonstrated preliminary findings, that
suggest that a culturally sensitive and mobile health lifestyle
intervention could be efficacious, promoting ideal cardiovascular
health among African Americans. I think what's so important about
this is that, they partnered with a very trusted group, the
churches, and getting buy-in to a community that has had many
reasons not to trust in the past, I think is critically
important.


Dr. Mercedes Carnethon:


Well, thank you so much, Karol. My third paper is an original
research investigation by Anoop Shah and colleagues from the
University of Edinburgh, arguing that socioeconomic deprivation
is an unrecognized risk factor for cardiovascular disease.


Dr. Mercedes Carnethon:


In their study, the authors evaluated how risk scores, with and
without indicators of socioeconomic deprivation, performed in a
population study in Scotland, the Generation Scotland: the
Scottish Family Health Study, of over 15,000 adults. Again, I
won't give away all the details, so that I keep our listeners
excited to read the article, but all risk scores aren't created
equally. And the observed versus expected number of events
varied, based on whether the risk score included socioeconomic
indicators or not. Further, the performance of the risk scores
varied, based on the degree of deprivation that participants were
currently experiencing. It's a thought provoking piece, that may
challenge us to reconsider how we identify risks for
cardiovascular disease in the population.


Dr. Mercedes Carnethon:


And I'm turning to you now, Fatima.


Dr. Fatima Rodriguez:


Sure thing, Merci. My last paper is led by Dr. Anna Krawisz, and
is looking at how differences in comorbidities explain racial
disparities in peripheral vascular interventions. This study used
Medicare fee for service data from 2016 to 2018, to examine risks
of death and major amputation, one year following peripheral
endovascular intervention. They found that, black Medicare
beneficiaries had higher population level need for peripheral
endovascular interventions, and that black race was associated
with adverse events following these interventions. However, after
adjusting for the higher prevalence of comorbidity, such as
diabetes, hypertension, and chronic kidney disease in black
populations, this observation was eliminated. Again, like a
common theme in many of the articles we've discussed today, this
is to suggest, that moving upstream to reduce risk factors is
really critical to eliminate disparities in cardiovascular
disease outcomes. And this includes the understudy disease of
peripheral arterial disease. Black adults were also less likely
to be treated with guideline directed medical therapies in this
study.


Dr. Mercedes Carnethon:


Well, thank you so much, Karol and Fatima, for your wonderful
summaries of all of the excellent pieces in this issue.


Dr. Karol Watson:


And I'd like to thank all of the fantastic investigators who
submitted their really fantastic work, so that we could produce
this issue. And really, keep them coming. We thank you for this.


Dr. Mercedes Carnethon:


Well, thank you. So now we'll transition to our feature
discussion with Drs. Wadhera and Kyalwazi, from Beth Israel
Deaconess Medical Center, and the Harvard Medical School.


Dr. Mercedes Carnethon:


Welcome to this episode of Circulation on the Run podcast. I'm
really pleased to host this feature discussion. My name is
Mercedes Carnethon, from the Northwestern University Feinberg
School of Medicine. And I'm pleased to have with us today, Drs.
Ashley Kyalwazi and Rishi Wadhera from Beth Israel Deaconess, and
the Harvard Medical School. And they shared with us a really
important piece of work for our disparities issue, that is
describing disparities in cardiovascular mortality, between black
and white adults in the United States from 1999 to 2019. First of
all, I really want to thank you both for submitting your
important work to circulation.


Dr. Rishi Wadhera:


Thanks so much Mercedes, and thanks for the opportunity to submit
and revise our manuscript.


Ms. Ashley Kyalwazi:


Thanks so much for having us.


Dr. Mercedes Carnethon:


Wonderful. I'd like to start out with you Rishi. Tell our
listeners about the objectives of your study, and what your
motivation was for carrying out this work.


Dr. Rishi Wadhera:


Well, I think it's been well established that, black adults are
disproportionately impacted by cardiovascular disease, and
experience worse cardiovascular outcomes, due to systemic
inequities and structural racism. And so, the goal of our study
was really, to perform a comprehensive national evaluation of how
age adjusted cardiovascular mortality rates have changed for
black adults, compared with white adults, over the past two
decades in the United States, with a focus on some key subgroups,
like younger adults and women.


Dr. Rishi Wadhera:


In addition, because we know that the neighborhood community or
environment in which you live in the US, has an immense influence
on cardiovascular health, we also examine changes in
cardiovascular mortality for black and white adults by geographic
region, rurality, and neighborhood racial segregation. And our
primary objective was really, to understand whether disparities
in cardiovascular outcomes between black and white adults
improved, worsened, or didn't change, from 1999 to 2019.


Dr. Rishi Wadhera:


And there are some reasons to think we might have made progress
in narrowing the mortality gap between these groups over this
time period. There have been substantial improvements in
preventative care and treatments for cardiovascular disease over
the past two decades. And the expansion of insurance coverage
under the Affordable Care Act, led to increases in access to
care, cardiovascular risk factor screening and treatment,
particularly, for black adults. At the same time, we know that,
black adults were disproportionately affected by the economic
recession of 2008, and experienced worsening poverty, job loss,
and wealth loss, all of which are inextricably tied to
cardiovascular health, and more broadly, health. And so that was
our interest in really exploring how disparities in
cardiovascular mortality have changed amongst black and white
adults between 1999 and 2019.


Dr. Mercedes Carnethon:


Thank you so much for that summary. It's really nice to have
these sort of pieces that really outline for us a lot of data,
and across a number of different domains. Because it allows us
really, a chance to think about those data, and how we can use
those data in order to help improve health.


Dr. Mercedes Carnethon:


So tell me a little bit, Ashley, about what your study found.


Ms. Ashley Kyalwazi:


Absolutely. Yeah. So in the United States, overall, we found that
age adjusted cardiovascular mortality rates declined for both
populations, so both black and white adults, by around 40% from
1999 to 2019. So encouraging declines across the country. We
found that these patterns were similar for both women and men,
when we stratified by gender, over the 20 year period. While
mortality rates declined in all regions, we still did find
disparities when we stratified by age. So between the younger and
older black women, versus younger and older black men, we found
that, younger black men and black women were dying at higher
rates, and were at increased risk of death from cardiovascular
mortality, compared to younger white women and men, respectively.
But we also found that black women and men living in rural areas
consistently experienced highest mortality rates. And then
finally, black adults living in higher areas of residential
racial segregation, and compared to those living in low to
moderate areas of residential racial segregation had higher
mortality rates, as well.


Dr. Mercedes Carnethon:


Wow, this is a lot. And it's really describing a lot of
disparities across multiple domains that we can easily measure.
Which aspects of these results in your work did you find the most
surprising, Ashley?


Ms. Ashley Kyalwazi:


Yeah, I was intrigued, I think overall, by just the gaps. I was
very encouraged by, I think, the declines over time. On an
absolute scale, the country has made a lot of progress, in terms
of reducing cardiovascular mortality rates for both groups. But
still, by the end of the study period, there were notable gaps
between black adults and white adults. Particularly, between
black, younger women and white, younger women, we see that by the
end of the study period, black, younger women still remain over
two times the risk of death from cardiovascular disease than
younger white women. Which I think, leaves something to be
desired from a public health and health policy standpoint, with
regards to how we're going to kind of decrease these disparities.


Dr. Mercedes Carnethon:


I wanted to follow up on that point. Why do you think you see
such disparities between black and white younger women? I love
the opportunity of the podcast to allow authors a chance to
speculate, beyond what they would do in the paper.


Ms. Ashley Kyalwazi:


Absolutely. I think that, there are a lot of great efforts on a
national scale right now, to kind of address the disparities
between black and white women. The Association of Black
Cardiologists, for example, had a whole paper out about ways to
really target and provide preventative measures for black women.
So for example, working with communities, where there's a high
proportion of black women, to figure out what community based
research looks like. Engaging with churches, different types of
methods, to really understand the barriers that black women face
towards obtaining preventative care.


Ms. Ashley Kyalwazi:


I think the disparities that we are seeing, could potentially
parallel well known and documented disparities in maternal health
outcomes. So I think, from a perspective of preventative care,
really thinking about, what are the barriers to healthy
cardiovascular profiles for black women pre and postnatally, to
ensure that their cardiovascular health is an actionable before
and after the pregnancy?


Ms. Ashley Kyalwazi:


And then I think, broadly, the challenges that black women face,
mirror the challenges of black adults, plus the additions of like
social stressors, things that we looked at in this study
neighborhood residential racial segregation, access to
healthcare, and all of those things kind of contribute to the
profile that black women face, in terms of being often, the heads
of their households as well, and carrying on a lot of different
societal challenges.


Dr. Mercedes Carnethon:


Thank you so much for that. I really appreciate that.


Dr. Mercedes Carnethon:


As I read the paper, one of the findings that I found the most
surprising, and it was challenging for me to understand, is that
while the absolute difference in rates was declining, or getting
smaller over time, between black and white men and women, the
rate ratios remained elevated across the course of time. I think,
these concepts can be a little challenging to understand, not
just to me, but to others as well. That when one measure of
effect is showing progress, but another is still reporting a
disparity.


Dr. Mercedes Carnethon:


Rishi, could you explain for our listeners, how we can see
progress on one metric, but still find a mortality rate ratio
that's 1.3 times higher in black, as compared with white men, for
example?


Dr. Rishi Wadhera:


Thanks for that really important question, Mercedes. Just to
summarize, we presented two outcomes that compared cardiovascular
deaths among black and white adults in our paper, absolute rate
differences, and then separately, rate ratios. And I think, both
measures provide important complementary insights. I think that,
understanding the absolute rate difference in cardiovascular
deaths is critically important from a public health perspective,
because it characterizes excess deaths experienced by black
adults, compared with white adults. The fact that the absolute
rate difference in cardiovascular death has narrowed over the
past two decades between these groups is positive news. In
contrast, the rate ratio provides us with important insights on
the relative difference, or disparity or gap, between black and
white adults.


Dr. Rishi Wadhera:


So again, both are important, both provide sort of synergistic
and complimentary insights. And just to sort of cement that, as
an example, you were talking to Ashley earlier, about some of the
patterns we noticed amongst younger black women and white women.
The absolute rate difference in cardiovascular deaths between
younger black women, compared to younger white women, decrease
from 91 per 100,000 in 1999, to about 56 per 100,000 in 2019. And
that's good progress. However, our rate ratio analysis indicated
that, still in 2019, young black women were 2.3 times more likely
to die of cardiovascular causes than young white women.
Highlighting that, we still have a lot of work to do, to address
disparities between these groups. Some of which, Ashley already
talked about.


Dr. Mercedes Carnethon:


Thank you so much for that excellent explanation. I know it's
certainly, I find it alarming to hear, but then I remember I'm
actually not young anymore. So maybe this doesn't apply to me
quite as much. But no, I appreciate the explanation.


Dr. Mercedes Carnethon:


So your report was really unique, in that you studied these
disparities, as we discussed, across a number of domains, age,
geography, even racial residential segregation. Whereas, the
pronounced disparities have been reported in a few of the other
domains that you studied. I'm really interested in hearing more
about racial residential segregation. I think, a lot of people
don't fully understand what the concept is, and the ways in which
racial residential segregation may contribute to higher rates of
cardiovascular death among blacks.


Dr. Mercedes Carnethon:


Ashley, would you mind explaining to us first, what racial
residential segregation is? And then really, how it would
contribute to higher rates of cardiovascular death?


Ms. Ashley Kyalwazi:


Yeah, absolutely. So in its simplest terms, racial residential
segregation is just the physical separation of two or more groups
by race and/or ethnicity into different neighborhoods. What gets
tricky is, like the long history within the United States of how
we got to this point, where you see numerous degrees of
segregation across the country. Residential racial segregation in
the United States dates back to policies pre World War II, that
resulted in kind of discriminatory banking practices and
policies. For example, reverse red lining and gentrification,
much of which the extent still exists today. And that's what we
see kind of, I think, in our results when we looked at high
versus low to moderate areas of residential racial segregation,
and how those kind of track onto the trends that we see in
cardiovascular mortality over time.


Ms. Ashley Kyalwazi:


The residential racial segregation impacts almost every aspect of
life. You can imagine where you live, we know definitely impact,
for example, your zip code can impact health outcomes. We've seen
individual's cardiovascular health kind of trend with something
as simple as your zip code. Where you live really does impact
your, for example, access to affordable housing, health
insurance, where your primary care physician is, whether or not
you even have one. What that trip looks like to see your primary
care physician, is it hours on end, and unrealistic to get to, or
is it just around the corner?


Ms. Ashley Kyalwazi:


Educational opportunities, which leads to income, which we know
is linked to cardiovascular disease employment in all of these
aspects. Even access to green space. In some metropolitan areas
that are more segregated, we see that, black adults, for example,
have less access to green space, and numerous studies have shown
that, that does impact overall health, but then also, from a
cardiovascular disease perspective as well. So I think that,
given that we know that lack of access to all of these key
determinants can adversely affect cardiovascular mortality, and
just general cardiovascular health, I think is very interesting
that we found that, there was this link between high residential
racial segregation and cardiovascular mortality. That we
definitely can look into more, and understand kind of in more
detail, that the mechanisms at play and ways to intervene.


Dr. Rishi Wadhera:


And just to layer onto and reinforce Ashley's really excellent
answer to that question. We know that black adults are more
likely to live in disadvantaged neighborhoods, because of the
intentionally racist policies that were put in place many decades
ago, that Ashley described so well. And black communities and
segregated communities, as Ashley mentioned, are less likely to
have access to primary care, high quality hospital care, and
green spaces, but also, pharmacies and healthy foods. And we also
know, there's a lot of empirical work that's shown that black
communities, disproportionately experience psychosocial
stressors, trauma.


Dr. Rishi Wadhera:


Also, these communities are disproportionately exposed to climate
change, such as extreme heat. There was a recent paper that
extreme heat has been linked to increases in cardiovascular
mortality, and disproportionately affects black communities.
These communities are also disproportionately exposed to
pollution. All of these things we know are linked to
cardiovascular health, and represent the effects of again,
intentionally racist policies that were put into place many
decades ago, the effects of which still persists today. Which
will require equally intentional policies that aim to dismantle
these longstanding effects, if we hope to make progress in
advancing health equity, and specifically, cardiovascular health
equity.


Dr. Mercedes Carnethon:


I appreciate the facility with which the two of you address the
multiple complex contributors to cardiovascular health. It's even
more impressive coming from two clinicians. So I really
appreciate you taking the time to explain this. And this is where
I really like the opportunity to open up and say, what more do
you want your clinical peers to know about? For example, how does
this affect the day to day encounters that you have in clinic
with black patients, and other patients who've been traditionally
underrepresented? How do you hope your clinical peers will use
this information to promote cardiovascular health equity? And
I'll open it up to either of you to respond.


Ms. Ashley Kyalwazi:


Yeah, I can get on that one. I think that, the disparities that
our paper highlights, really requires a multisystem level
approach to tackling, from public health to public policy. But I
think at a provider level, to your question, Mercedes, physicians
must be able to, I think at first, read the data and understand
that these disparities exist.


Ms. Ashley Kyalwazi:


If there's no insight with regards to the risk profiles, that
simply black women and black men have, because of systemic
racism, because of these inequities, then I think, we're already
kind of steps behind where we need to be. So recognizing
disparities in cardiovascular disease burden for black men and
women, prioritizing education on cardiovascular risk. A lot of
the conditions are preventable with appropriate access to care
and education around these topics. And so, providing education
about the signs and symptoms of heart disease and treatment
options for black men and women. Recognizing the history of
medical mistreatment for black adults in this country. And
really, tailoring the approach towards the individual who comes
into the office, who might have very valid reasons for hesitating
to take a medication, or a lot of questions that need time and
consideration.


Ms. Ashley Kyalwazi:


At a research level, I think, more data and resources should be
spent on studying risk prevention and treatment for
cardiovascular disease in black adults, and really, developing
more community based models, that really get at the specific
interventions that work within black communities, that are
culturally specific, that are targeted and relevant, for the
populations that we're talking about.


Ms. Ashley Kyalwazi:


I think finally, and I'll let Rishi chime in, I think, this is
shockingly low level of racial and ethnic representation in the
field of cardiology as a whole. And we know that, diversity in
healthcare can improve health outcomes. So from a cardiology
perspective, I think, training the next generation of black young
men and women to take up their seats at the table, and really
advocate for some of these issues, alongside individuals who are
already doing great work, would be essential towards reducing
disparities that we see. And so all of the above, I think, I
would encourage for my colleagues.


Dr. Mercedes Carnethon:


Thank you so much. Rishi, any final thoughts?


Dr. Rishi Wadhera:


No, I'll just add onto Ashley's again, really outstanding
response that, this is a tension we face when we see patients in
cardiology clinic all the time. I think, awareness about
disparities, and the multiple factors that contribute to
disparities in cardiovascular health, particularly, as it relates
to race and ethnicity, are increasingly being recognized as they
should be.


Dr. Rishi Wadhera:


And one of the challenges, how much can clinicians do within the
bounds of hospital walls? We can make sure that we get patients
the treatments they need. We can make sure we screen patients
appropriately. But we know, as we've discussed, that so many
factors beyond hospital walls, like widening income inequality,
that's disproportionately affected black adults, and has been
worsening over the last several decades. Widening educational
inequality, that again, disproportionately affects black adults,
and has been worsening over decades, also affect how. So I think,
thinking about how clinicians, researchers, and policy makers,
can work together to address some of these challenges, issues,
and broader social determinants of health, that also exist
outside our clinical practice, or hospital walls, will be really,
really important, if we are serious about advancing health equity
in this country.


Dr. Rishi Wadhera:


I don't think, we can operate in silos anymore. In the clinical
world, in the research world, in the policy making world, we need
more researchers and clinicians to have a seat at the table when
it comes to policy making, individuals who understand how all of
these complex factors are inextricably tied to one another, so
that we can seek and implement solutions that advance
cardiovascular health.


Dr. Mercedes Carnethon:


Thank you so much. The insights that we've gotten, from not only
your written work, but even more importantly, this opportunity to
speak with you today, and share with our readership, have just
been invaluable. And I really appreciate the amount of time that
you spent, in preparing the manuscript, and really
contextualizing the findings with us today, as well as in
writing. So thank you so much for contributing this really
important work to our annual disparities issue.


Dr. Rishi Wadhera:


Thank you so much, Mercedes. We really appreciate all the time
you and the Circulation team took to make the manuscript
stronger.


Ms. Ashley Kyalwazi:


Thank you so much for having us. It was truly an honor to have
this conversation and to submit our work.


Dr. Mercedes Carnethon:


Well, thank you.


Dr. Mercedes Carnethon:


That wraps up our feature discussion for this episode of
Circulation on the Run podcast. I'm Mercedes Carnethon, from
Northwestern University, Associate Editor and guest editor of the
disparities issues. So thank you so much.


Dr. Greg Hundley:


This program is copyright of the American Heart Association,
2022. The opinions expressed by speakers in this podcast are
their own, and not necessarily those of the editors, or of the
American Heart Association. For more, please visit
hajournals.org.